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psnet.ahrq.gov/node/838126/psn-pdf
September 21, 2022 - Sustained improvement in quality of patient handoffs
after orthopaedic surgery I-PASS intervention.
September 21, 2022
Stenquist DS, Yeung CM, Szapary HJ, et al. Sustained improvement in quality of patient handoffs after
orthopaedic surgery I-PASS intervention. J Am Acad Orthop Surg Glob Res Rev. 2022;6(9):e22.0007…
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psnet.ahrq.gov/node/866161/psn-pdf
June 19, 2024 - Patient Safety Indicators at an academic veterans affairs
hospital: addressing dual goals of clinical care and
validity.
June 19, 2024
Allaudeen N, Schalch E, Neff M, et al. Patient Safety Indicators at an Academic Veterans Affairs Hospital:
Addressing Dual Goals of Clinical Care and Validity. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/38935/psn-pdf
March 01, 2017 - Leadership committed to safety.
December 23, 2016
Sentinel Event Alert. August 27, 2009;(43):1-3.
https://psnet.ahrq.gov/issue/leadership-committed-safety
Despite the past decade's focus on improving patient safety, most health care organizations are still striving
to achieve high reliability status—consistently p…
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psnet.ahrq.gov/node/837063/psn-pdf
May 11, 2022 - Patients' experiences and perspectives of patient-
reported outcome measures in clinical care: a systematic
review and qualitative meta-synthesis.
May 11, 2022
Carfora L, Foley CM, Hagi-Diakou P, et al. Patients’ experiences and perspectives of patient-reported
outcome measures in clinical care: a systematic revie…
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psnet.ahrq.gov/node/61121/psn-pdf
November 11, 2020 - Out of sight, out of mind: a prospective observational
study to estimate the duration of the Hawthorne effect on
hand hygiene events.
November 11, 2020
Vaisman A, Bannerman G, Matelski J, et al. Out of sight, out of mind: a prospective observational study to
estimate the duration of the Hawthorne effect on hand hy…
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psnet.ahrq.gov/node/854384/psn-pdf
January 01, 2024 - Look-alike medications in the perioperative setting:
scoping review of medication incidents and risk reduction
interventions.
October 11, 2023
Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of
medication incidents and risk reduction interventions. Int J Clin Ph…
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psnet.ahrq.gov/node/856586/psn-pdf
November 29, 2023 - The complexities of communication at hospital discharge
of older patients: a qualitative study of healthcare
professionals' views.
November 29, 2023
Cam H, Wennlöf B, Gillespie U, et al. The complexities of communication at hospital discharge of older
patients: a qualitative study of healthcare professionals’ view…
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psnet.ahrq.gov/node/865976/psn-pdf
May 29, 2024 - What do patients and families observe about pediatric
safety?: A thematic analysis of real-time narratives.
May 29, 2024
Studenmund C, Lyndon A, Stotts JR, et al. What do patients and families observe about pediatric safety?:
A thematic analysis of real?time narratives. J Hosp Med. 2024;19(9):765-776. doi:10.1002/j…
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psnet.ahrq.gov/node/847045/psn-pdf
April 05, 2023 - Healthcare-associated infections in Veterans Affairs
acute-care and long-term healthcare facilities during the
coronavirus disease 2019 (COVID-19) pandemic.
April 5, 2023
Evans ME, Simbartl LA, Kralovic SM, et al. Healthcare-associated infections in Veterans Affairs acute-care
and long-term healthcare facilities d…
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psnet.ahrq.gov/node/72521/psn-pdf
December 02, 2020 - I-PASS illness diversity identifies patients at risk for
overnight clinical deterioration.
December 2, 2020
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical
deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/jgme-d-19-00755.1.
https://psn…
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psnet.ahrq.gov/node/837602/psn-pdf
January 01, 2023 - Outcome differences between surgeons performing first
and subsequent coronary artery bypass grafting
procedures in a day: a retrospective comparative cohort
study.
June 29, 2022
Zhang D, Gu D, Rao C, et al. Outcome differences between surgeons performing first and subsequent
coronary artery bypass grafting proced…
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psnet.ahrq.gov/node/72548/psn-pdf
January 01, 2021 - Better nurse staffing is associated with survival for Black
patients and diminishes racial disparities in survival after
in-hospital cardiac arrests.
December 9, 2020
Brooks Carthon M, Brom H, McHugh MD, et al. Better nurse staffing is associated with survival for black
patients and diminishes racial disparities i…
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psnet.ahrq.gov/node/836824/psn-pdf
March 30, 2022 - Collaborative case review: a systems-based approach to
patient safety event investigation and analysis.
March 30, 2022
Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient
safety event investigation and analysis. J Patient Saf. 2022;18(2):e522-e527.
doi:10.1097/pt…
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - be prevented if things
were handled perfectly, the argument would be that we need a standard way of assessing
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - Castle: Most of my work in nursing homes has revolved around assessing quality: what
makes a quality
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing
Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to
Prevent Patient Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…